Dissection at the base of the bladder to reach the
anterior vaginal wall and uterine cervix creates edema, interrupts
the small nerve pathways, and thereby sets up the physiologic changes
that produce urinary bladder atony. Therefore, catheter drainage of
the urinary bladder is an essential feature of many pelvic surgical
procedures. Fortunately, in most cases, these conditions reverse themselves
in 3-5 days, and catheter drainage is no longer needed.

Suprapubic bladder
catheterization is superior to transurethral bladder catheterization
because it is cleaner. It also leaves the urethra open for voiding
when urinary function has returned. The use of an ordinary Foley catheter
(No. 16 French with 5-mL bag) is preferable to the commercially available
suprapubic catheter kits because a Foley catheter, when inserted as
described in this section, is usually not dislodged from the bladder
during sleep or activity. In addition, the Foley catheter is less costly
and is available in all surgical clinics. The instrument used for insertion
of the Foley catheter is an ordinary Randall stone forceps. The fulcrum
of this instrument is toward the rear, which keeps the overall diameter
of the axis virtually unchanged except at the jaws and gives it an
advantage over a Kelly clamp.

The operation provides drainage of the
urinary bladder through a clean surgical incision and ensures that
the catheter does not slip out of the patient or become dislodged within
the abdominal wall.

Physiologic Changes. The procedure reduces edema
at the base of the bladder, allowing the return of normal vesical function.

Points of Caution. After
grasping the catheter with the jaws of the Randall forceps (Fig.
4) and before inflating the Foley balloon, the catheter should be
drawn through the bladder until the tip can be seen in the urethral
meatus. This ensures that the catheter tip and balloon are in the
bladder and not in the subcutaneous or subfascial space.

Technique

This procedure can be performed
in the inpatient treatment rooms of a hospital, clinic, or
doctor's office. Local anesthesia is adequate for most patients.
The bladder does not have to be empty. The patient is placed
in the dorsal lithotomy position. The periurethral area and
suprapubic area are surgically prepped and draped. A routine
pelvic examination is performed prior to placement of the suprapubic
catheter. If local anesthesia is to be used, a 4 x 4 cm area
around the insertion site is infiltrated with 1% lidocaine.
Infiltration should include the fascia and, if at all possible,
a small area of the bladder wall.

A Randall stone forceps is inserted through
the urethral meatus and used to elevate the dome of the bladder
from the inside, pushing the suprapubic abdominal wall upward
to the palpating finger.

Upward pressure is maintained on the forceps,
and a small incision is made in the suprapubic skin and fascia
until the forceps can be felt with the blade of the knife.

A sudden upward thrust of the forceps pierces
the bladder wall and pushes the forceps through the incision.
The jaws of the forceps are opened and used to grasp the tip
of the Foley catheter.

The Foley catheter is pulled through the
bladder, and the forceps is withdrawn from the urethra until
the tip of the Foley catheter can be seen in the urethral meatus.

Traction is
placed on the Foley catheter from above while the balloon is
simultaneously inflated. This draws the catheter back into
the body of the bladder.

When
5 mL of sterile saline solution have completely filled the
Foley balloon, the catheter is firmly retracted upward.

It
is not necessary to suture the catheter to the abdominal skin.
A sterile dressing is applied, and the Foley catheter is connected
to straight drainage.